Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS-Outpatient)
Company: Veterans Health Administration
Location: Richmond
Posted on: April 9, 2021
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Job Description:
Applicants pending the completion of educational or
certification/licensure requirements may be referred and
tentatively selected but may not be hired until all requirements
are met. Basic Requirements: United States Citizenship:
Non-citizens may only be appointed when it is not possible to
recruit qualified citizens in accordance with VA Policy. English
Language Proficiency: Proficient in spoken and written English as
required by 38 U.S.C. -- 7403(f). Experience & Education:
1. Experience. 1 year of creditable experience that indicates
knowledge of medical terminology, anatomy, physiology,
pathophysiology, medical coding, & the structure and format of a
health records.-OR- 2. Education. An associate's degree from an
accredited college or university recognized by the U.S. Department
of Education with a major field of study in health information
technology/health information management, or a related degree with
a minimum of 12 semester hours in health information
technology/health information management (e.g., courses in medical
terminology, anatomy & physiology, medical coding, & introduction
to health records)-OR- 3. Completion of an AHIMA approved coding
program, or other intense coding training program of approximately
one year or more that included courses in anatomy & physiology,
medical terminology, basic ICD diagnostic/procedural, & basic CPT
coding. The training program must have led to eligibility for
coding certification/certification examination, & the sponsoring
academic institution must have been accredited by a national U.S.
Department of Education accreditor, or comparable international
accrediting authority at the time the program was completed-OR- 4.
Experience/Education Combination. Equivalent combinations of
creditable experience & education are qualifying for meeting the
basic requirements. The following educational/training
substitutions are appropriate for combining education & creditable
experience:
(a) 6 months of creditable experience that indicates knowledge of
medical terminology, general understanding of medical coding and
the health record, & 1 year above high school, with a minimum of 6
semester hours of health information technology courses.
(b) Successful completion of a course for medical technicians,
hospital corpsmen, medical service specialists, or hospital
training obtained in a training program given by the Armed Forces
or the U.S. Maritime Service, under close medical & professional
supervision, may be substituted on a month-for-month basis for up
to six months of experience provided the training program included
courses in anatomy, physiology, & health record techniques &
procedures. Also, requires six additional months of creditable
experience that is paid or non-paid employment equivalent to a MRT
(Coder). Grade Determinations: GS-09 Experience. One year of
creditable experience equivalent to the journey grade level of a
MRT (Coder-Outpatient);
OR, An associate's degree or higher and three years of experience
in clinical documentation improvement (candidates must also have
successfully completed coursework in medical terminology, anatomy
and physiology, medical coding, and introduction to health
records);
OR, Mastery level certification through AHIMA or AAPC and two years
of experience in clinical documentation improvement;
OR, Clinical experience, such as Registered Nurse (RN), Medical
Doctor (M.D.), or Doctor of Osteopathy (DO), and one year of
experience in clinical documentation improvement. Certification.
Employees at this level must have either a mastery level
certification or a Clinical Documentation Improvement
Certification. Master Level Certification: Certification is limited
to those obtained through AHIMA or AAPC. To be acceptable for
qualifications, the specific certification must represent a
comprehensive competency in the occupation. Stand-alone specialty
certifications do not meet the definition of mastery level
certification & are not acceptable for qualifications.
Certification titles may change & certifications that meet the
definition of mastery level certification may be added/removed by
the above certifying bodies. However, current mastery level
certifications include: Certified Coding Specialist (CCS),
Certified Coding Specialist - Physician-based (CCS-P), Registered
Health Information Technician (RHIT), Registered Health Informatic
Administrator (RHIA), Certified Professional Coder (CPC), Certified
Outpatient Cordera (COC), Certified Inpatient Coder (CIC). Clinical
Documentation Improvement Certification: This is limited to
certification obtained through AHIMA or the Association of Clinical
Documentation Improvement Specialists (ACDIS). To be acceptable for
qualifications, the specific certification must certify mastery in
clinical documentation. Certification titles may change, &
certifications that meet the definition of clinical documentation
improvement certification may be added/removed by the above
certifying bodies. However, current Clinical Documentation
Improvement Certifications include: Clinical Documentation
Improvement Practitioner (CDIP) & Certified Clinical Documentation
Specialist (CCDS). You must also demonstrate the following
KSAs:
1. Knowledge of coding and documentation concepts, guidelines, and
clinical terminology.
2. Knowledge of anatomy & physiology, pathophysiology, and
pharmacology to interpret & analyze all information in a patient's
health record, including laboratory & other test results to
identify opportunities for more precise and/or complete
documentation in the health record.
3. Ability to collect & analyze data & present results in various
formats, which may include presenting reports to various
organizational levels.
4. Ability to establish & maintain strong verbal & written
communications with providers.
5. Knowledge of regulations that define healthcare documentation
requirements, including The Joint Commission, CMS, & VA
guidelines.
6. Extensive knowledge of coding rules & regulations, to include
current clinical classification systems such as ICDCM & PCS, CPT, &
HCPCS. They must also possess knowledge of complication or
comorbidity/major complication or comorbidity (CC/MCC), MS-DRG
structure, & POA indicators.
7. Knowledge of severity of illness risk of mortality, complexity
of care for inpatients, & CPT Evaluation & Management (E/M)
criteria to ensure the correct selection of E/M codes that match
patient type, setting of service, & level of E/M service provided
for outpatients.
8. Knowledge of training methods & teaching skills sufficient to
conduct continuing education for staff development. The training
sessions may be technical in nature or may focus on teaching
techniques for the improvement of clinical documentation issues.
May qualify based on being covered by the Grandfathering Provision
as described in the VA Qualification Standard for this occupation
(only applicable to current VHA employees who are in this
occupation and meet the criteria). References: VA Handbook
5005/122, Part II, Appendix G57 MEDICAL RECORD TECHNICIAN
Qualification Standard, dated December 10, 2019. This can be found
in the local Human Resources Office. The full performance level of
this vacancy is GS-9. Physical Requirements: Light lifting (under
15 pounds); light carrying (under 15 pounds); use of fingers; both
hands required; hearing (aid permitted); sitting for up to 8 hours;
repetitive motions for computer data entry.
Keywords: Veterans Health Administration, Richmond , Medical Records Technician (Clinical Documentation Improvement Specialist) (CDIS-Outpatient), Healthcare , Richmond, Virginia
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